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Chronic Liver Disease +/- Portal HTN

 

Thank you for asking me to examine Harry, who presented with abdominal fullness.

 

My salient findings were stigmata of chronic liver disease associated with prominent abdominal veins, hepatosplenomegaly and shifting dullness, suggestive of portal hypertension.

 

On general inspection, Harry appeared comfortable. He did / did not appear cachectic. He was / was not jaundiced.

 

On inspection of the abdomen, there were / were not surgical scars. There was / was not obvious distension with striae, associated with / without prominent veins. Direction of flow was away from the umbilicus, suggestive of portal hypertension. There were / were not scars consistent with previous ascitic taps.

 

On palpation, there was / was not a palpable mass extending from the left upper quadrant inferiorly and medially to ____ cm below the costal margin and / without crossing the midline. There was no palpable upper edge, it moved inferomedially on inspiration, and there was a palpable notch, and hence believe it is consistent with splenomegaly. It was / was not tender and had a smooth texture.

 

There was associated hepatomegaly with an estimated liver span of ____ on percussion. It was non-tender and had a smooth / irregular /pulsatile edge.

 

On percussion, there was / was not shifting dullness, suggesting ascites.

 

Bowel sounds were normal / absent.

 

On further examination, there were signs suggestive chronic liver disease and I examined for complications of this.

  • There were / were not peripheral stigmata of chronic liver disease in the hands, more specifically findings of clubbing, leukonychia, palmar erythema, small muscle wasting, and Dupuytren’s contracture. There was / was not a hepatic flap.

  • There was / was not spider naevi in the arms and chest. There was / was not gynaecomastia.

  • There was / was not easy bruising and muscle wasting.

  • There were / were not scratch marks.

  • In the face, there was / was not scleral icterus or conjunctival pallor. In the mouth there was / was not stomatitis, leukoplakia, gingivitis, bleeding, or atrophic glossitis. There was / was not fetor hepaticus.

  • There was / was not muscle wasting and bruising in the legs

  • The JVP was ___ cm above the sternal notch. There was / was not sacral oedema, peripheral oedema, and vesicular breath sounds.

 

In terms of the aetiology of chronic liver disease:

  • There were / were not specific signs of a specific underlying aetiology with no markers of IV drug use or tattoos, no Kayser Fleischer rings, parotitis or Dupuytren’s contracture suggestive of alcohol use, no hyperpigmentation of haemachromatosis, and no deep jaundice with scratch marks and xanthelasma which may indicate primary biliary cirrhosis. 

 

In summary, Harry presented with abdominal fullness. My findings suggest chronic liver disease complicated by portal hypertension with/without features of decompensation (jaundice, ascites, encephalopathy, variceal haemorrhage, hepatorenal syndrome). I could/could not elicit a specific underlying aetiology today.

 

Other differentials for hepato/splenomegaly include:

  • Mention lists from below

 

I would proceed from here by:

  • Confirming my diagnosis with the combination of LFTs, INR, FBE to assess platelet count, an ultrasound of the liver, and a Fibroscan.

  • Assessing for an aetiology by:

    • Taking a history

    • Hepatitis B and C serology

    • Anti-mitochondrial antibody testing for primary biliary cirrhosis

    • ANA, smooth muscle antibody and anti-liver and kidney microsomal antibodies for autoimmune hepatitis

    • Iron studies, serum copper and caeruloplasm (in a young patient)

    • Alpha-1 antitrypsin level

  • Calculating the Child-Pugh score to help assess severity (bilirubin, albumin, ascites, encephalopathy, INR)

  • Evaluating for complications:

    • Screening for HCC

    • Screening for varices

    • UEC for hepatorenal syndrome and hyponatraemia

 

What are the differentials for chronic liver disease?

  • Common - alcohol, NASH, HBV, HCV

  • Genetic - Wilson’s, haemochromatosis, A1AT deficiency

  • Autoimmune - PBC, PSC, AIH

  • Other - drug related, Budd Chiari

 

What are the differentials for hepatomegaly? (Normal ~12.5cm on liver span)

By mechanism:

  • Acute hepatitis (tender)

  • Impaired outflow (tender)

    • Congestive heart failure (MASSIVE)

    • Budd Chiari

  • Cholestatic diseases

    • PBS, PSC

  • Storage disorders

    • Steatosis from NASH or alcoholic liver disease (MASSIVE)

    • Haemochromatosis

    • Wilson

    • AAT

    • Glycogen storage disorders

  • Infiltrative

    • Haematological disease - myeloproliferative (MF, PRV rare), CLL, lymphoma

      • Apparently MPNs can be massive according to Talley, but in reality, unusual

    • HCC and other tumours/mets (MASSIVE)

    • Rarer - amyloidosis, sarcoidosis

  • Other:

    • PKD

    • Acromegaly

​

By size:

  • "Massive"

    • Metastases​

    • ALD with fatty infiltration

    • Myeloproliferaitve disease

    • HCC

    • Right heart failure

  • Moderate​

    • Above causes​

    • Haemochromatosis

    • Haematological - CML, lymphoma

    • Fatty liver

  • Mild​

    • Above causes​

    • Cirrhosis

    • Hepatitis

    • Biliary obstruction

    • Amyloidosis and other infiltrative diseases

​

What are the differentials of splenomegaly?

By mechanism 

  • Chronic liver disease with portal hypertension

  • Haematological:

    • Myeloproliferative - myelofibrosis, CML, PRV, ET

    • Lymphoproliferative - lymphoma, CLL, leukaemia

    • Thalassaemia

  • CTD - RA, SLE

  • Infiltrative - amyloidosis, sarcoidosis

  • Storage - Gaucher’s disease

  • Infective - viral, bacterial, malaria

  • Other - acromegaly

By size:

  • Massive - CML, myelofibrosis, primary lymphoma, HCL, malaria

  • Moderate - above + pHTN, lymphoma, leukaemia, thalassaemia, storage diseases

  • Small - the above, MPNs, infections (viral), connective tissue disease, infiltration (amyloid, sarcoid)

 

What are the differentials for hepatosplenomegaly?

  • CLD with portal hypertension

  • Haematological - MPNs, lymphoma, leukaemia, sickle cell anaemia

  • Infection - viral hepatitis, glandular fever

  • Infiltration - amyloidosis, sarcoidosis

  • CTD - SLE

  • Acromegaly

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